How to talk to patients with an EMR in the room

I see a lot of articles by physicians complaining about how the use of a computerized medical record (EMR) in the exam room with patients detracts from the physician-patient experience.

The complaint usually follows the theme that the physician and patient are not able to have eye contact, and both the physician and the patient feel less intimate and connected during the visit because the physician’s need to use the keyboard, mouse and look at the monitor detract from the personal interaction.

I’ve been using an EMR in the exam room since 1997, and although the interaction with patients is somewhat different than it was with a paper chart I have found that it is very possible for the time with patients to be at least a good now with the EMR. I am convinced that my patients feels good about the experience too. Many of the problems physicians have can be overcome by intentionally doing a few things right. Here is my list of things to do and not to do:

1. Most important is to never, ever complain about the EMR to the patient. Let them know that you are using the EMR to help you take better care of them. If at times you struggle with an IT issue or face a learning curve problem in starting up on the EMR, don’t whine in front of the patient. If you tell the patient the EMR is detracting from their care, with words, body language, or otherwise, they will of course believe you, and will resent that you are allowing this to happen.

2. Substitute voice contact for eye contact. By this I mean involve the patient in your documentation or searching for data. Say, “It’s really important that I make an accurate note of the details of your injury in case this ever becomes important in the future.” Then read aloud what you are typing as you enter the details. If you are looking up the patients last cholesterol level, talk your way through the process, and read the results to them. This way they see that you are working for them, and they see how useful the good records you keep are in providing good care for them.

3. Tell patients how you make use of the IT strengths of your system. If you use secure messaging for communication tell them why you prefer to use it, i.e. more secure, faster, less chance of miscommunication, etc. If you use the system for recalls, reminders of services due or electronic prescriptions tell them how you are using these features to provide convenience.

4. Explain why you do certain things. A patient asked me why I urged him to have a photo on his chart. He felt this was an invasion of his privacy. He was more than happy to have a photo on his record when I explained it was a safety issue, making me less likely to accidently give him someone else’s prescription or test results by seeing his photo when I open a chart, and that it helped me remember the details of his visit when I had a photograph of him to prompt my recall.

5. Try to find a reason to get the patient to look at something on the monitor with you. Show them their child’s growth curve, or their last several HbA1C or LDL results, or review their MRI report with them. This helps them see why you are looking at the monitor, and gives them confidence the EMR lets you see data in a way that benefits them. Almost all patients want you to have the tools you need to take good care of them. If they see the EMR as a tool, just like a stethoscope or reflex hammer, they will feel good about their doctor making good use of that tool.

6. Every visit needs a warm greeting, and a warm closure. The EMR can get in the way of this if you let it happen. Greet the patient with physical and eye contact. A warm handshake and greeting starts any visit well. At the end of the visit again physically and emotionally close the visit. This means again eye contact, usually physical contact in an age and gender appropriate way, and something to let them know the visit is over. This has always been important, but is even more important with an EMR, and is easier to miss now when we can be engrossed in hurrying to finish typing the assessment or plan, and can skip the needed visit closure.

If you follow these guidelines, I bet you get few complaints from patients, and start to feel much better about using the computer in the room with your patients.

How to talk to patients with an EMR in the room 29 comments

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http://www.meaningfuluses.com Faisal Qureshi

Agree with all 6 Dr. Pullen. If there was a #7: Minimize the time spent using the EMR. Tips I’ve given during training EMRs include making sure staff enters all information before entering the room, so the MD focuses only on the good stuff like chart notes. For some, using templates to pre-fill norm values, and only change what’s unique to that patient.

I’m curious to know your thoughts on physician stress from patients bombarding questions while physician is trying to work with the EMR at the same time. It’s far more intuitive to listen and write with a pen and a pad.

http://drpullen.com Ed Pullen

I think dealing with questions and doing EMR at the same time is touch typing, so you can look up and still type, asking patients to wait for you occationally, and a just being relaxed about it.

http://www.CareerMedicine.com CareerMedicine

One patient switched from a colleague’s practice to mine because “The doctor did not even lift her eye from the keyboard!!”

I recommend that since EMR are now almost mandatory, all physicians need to learn typing. That will alleviate most of these complaints and make physician work more efficient. Being able to type at a good speed will not only complete the chart as the visit comes to an end but also keep patients contended with the visit.
May be Medical Schools now should make Typing classes mandatory for students. Yes! Why not?

http://drpullen.com Ed Pullen

I tell my patients that the only class in high school that I did not get an “A” in is the one class that I use every day. Typing.

Dr. Pi

i often tell my patients the most important class I had in high school was typing. And the most used thing (some dreary days) I got out of medical school was the MD after my signature on form after form after form.

stargirl65

I have intuitively incorporated all the above into my interactions. I can touch type information that is not easily clicked on. When accessing other information I narrate loosely what I am doing. I often have patients look at the flowsheets and graphs in the chart. One lady started crying (in relief) when she saw how much weight she had lost. She said seeing it made it more real and she felt all her hard work had paid off.

There have been a few times when I input into the record after the encounter. Most of these involve severely emotional encounters or occasionally a procedure I document after finishing.

I do like my system. I just wish it could talk with more systems.

http://drpullen.com Ed Pullen

Agreed, never believe a salesperson who says an interface is easy. After 11 years our EMR still has very limited interface with the systems at our community hospital.

Geordon VanTassle

Recently, I had the need to see my physician. The group that I see uses an EMR, and has for years.

This time, though, was a little bit disconcerting, since the physician locked eyes with me while sitting at a 45 degree angle to me, typing away at the EMR. Granted, he was a very fine typist, but it was actually a distraction for me for him to be interacting with me in this way.

I particularly liked the point about verbal contact as an alternative to eye contact. My PCP (not the guy that I saw in this instance) does that a lot, and I find that it is much more reassuring than the locked eye contact.

Max

I’m sorry but there is no substitute for eye contact. It’s been held in the highest regard since time began. In shaking hands with someone. In courtrooms. In officer testimony. In truth telling. In trustworthiness. Etc. Eye contact in every ancient and modern society has meant something and it will always mean something. If you were buying a car and the salesman never looked you in the eye, would you trust him? Yeah, I wouldn’t eiher.

http://drpullen.com Edward Pullen MD

Of course eye contact is important, but given that it is important to review data while in the room with patients, voice contact can be a useful and valuable adjunct.

pheski

I agree with the thrust of Dr Pullen’s post. The comments are also good. But why does no one mention the elephant in the room: multitasking is an illusion.

Good data shows that use of a cell phone (with head set) while driving has the same impact on attention, retention and reaction time as being legally intoxicated.

Navigating most current eHRs (I didn’t say modern eHRs because none of them are modern) is far more complex than talking on a cell phone. And collecting and analyzing clinical information during a patient encounter is far more cognitively demanding than driving a car.

I submit that we (I do it, too) are all seriously impaired during the time we are typing or navigating while asking questions or listening to answers. I would love to see some studies done. I doubt that any of the eHR companies would come within a mile of such a study. Any folks out there with access to a residency program, functional PET scanning and a cognitive psychology department?

P

jsmith

You are correct, sir or madam. Farting around with the computer does not mix with good doctoring.

ggmd

For those of us who don’t type very well, it’s excrutiating. I have to look at the keyboard when I type. Our ED put all of the computers in corners so we can’t face the patient when we type. I applaud your success, but EMR implementation has been enough for me to consider cutting back my hours and search for other revenue streams. It’s not for patients or us…it’s for bean counters and managers.

Rob

Ed:
You must have had a really smart doctor demo your EMR.

http://drpullen.com Edward Pullen MD

Good chance.

http://nostrums.blogspot.com Doc D

Aren’t you worried that patients will view all these tips and techniques as…well…tips and techniques to excuse why a part of your conscious mind is elsewhere?

Would you feel comfortable if a teenager could keep their eyes on the road while still texting to another person? I’m not sure this makes the driver safe, and I’m likewise not sure the physician is focused where they should be while typing…no matter where their eyes are, or how they engage the patient in the process of documenting.

Before people jump on my case, I follow the author’s suggestions. I don’t have the time to document after the patient leaves. And heaven forbid that I forgot to ask about something for which there’s a required text entry box in the EMR.

So, I’m just not totally comfortable with all this.

jsmith

Wrong! Wrong!! Wrong!!!
This is how to do it. This is how I do it. You look up the info you need before you go in to see the pt, and you do not use the EMR in the room. Rarely, you need to look at the computer. If you must pervert the doctor-pt interaction in this way, you apologize profusely and get off the EMR as soon as you can.
When you are done with the visit, you go back to your office and dictate the visit, including changes to meds and the problem list. You also send the meds to pharmacy, the orders to the lab, etc.
No transcriptionist, you say? Easy solved: get one. If your employer balks, get a new job. Next case.

r watkins

Exactly! The patient is paying for face-to-face time with the doc; documentation (whether by writing, dictating, or typing) is incidental to the visit, though necessary, and should not done in a way that compromises the visit. It is rude and disrepectful to sit in front of the patient and do secretarial chores during time that they are paying for.

The idea that all the chart work has to be completed in the exam room during the visit has become especially pervasive since the intro of EMRs (organizations can save bucks by turning docs into data entry clerks) and definitely degrades the quality of the visit.

Dr. Pi

Totally agree.

marlene

Yes! I have been turned into the secretary – for the insurance company and the trial lawyer. So… how about they pay me for that time after the visit. Thats the way I practice now- interact fully with the patient and document out of sight, after visit, after hours, during lunch, during dinner.
I have recently been informed that an EMR will necessitate change in the way I do thinks. I will chart as I go, document in real time- and let my patient see all this high tech secretarial service while paying attention to his questions and while looking for the appropriate checkbox and shifting from a GI complaint to his cholesterol data. And I’m gonna SMILE!
And I will worry that I am a distracted clinician- did I miss his subtle statement that was THE KEY to the drumroll please… patient open ended history they taught me in med school that would hold all the answers anyway. And I might drop the laptop when he shoves out his leg for me to see his new boo boo.
Yes, medicine is changing, like alot of change in our country these days. All that hopey changey stuff. Like money growing on trees and your doctor looking at you while typing with the hand you aren’t shaking and you getting tangled in the cord when he tries to put a supportive hand on your shoulder. Your doctor- who can listen , support assess, work through a differential, examine, and defensively document SIMULTANEOUSLY, about your mulitple concerns for todays visit.
Would it really be that much more expensive to videotape with audio every visit? They could carry it as a personal health CD library.
And I could go home. After the one or two lines in the chart that are all … I say ALL I REALLY NEED… to practice undefensive unreimbursed medicine. The ins execs and lawyers can watch it on tape for what they need.
I will smile for the camera- and wave with both hands!

TNF

Hmm…personally I still want my doctor looking at ME when I’m sick. I realize that my case probably isn’t all that special that it requires 100% of his/her attention but I’ll probably look for an older, paper based doc once I get out of grad school.

Max

Plus let me just add the physician just looks silly sitting there in a white coat typing and talking. It makes them look like a transcriptionist or a secretary. And all the while, you’re telling them why you’re doing it and justifying it and saying how good it is for them you’re typing instead of spending the proper amount of the time looking at them and examining them. To the patient “You’re gonna love this!”. Patient: “Why?”

madoc

I like eye contact.
But the most important thing is thinking about that person and what they might need, that day.

marlene

Oh gosh that sounds nice. It’s what I signed up for. It’s what I thought it would be about. Yeah- that’s why I come here every day. Thanks for the reminder. It is what it is all about. Patients, and their needs. The rest- is just details. =)

alex

How utterly depressing. “Voice contact”. What in the f— is wrong with health care in this country? Anyone who has seen patients for more than a year will realize the vast majority care far more about whether you appeared to care (which involves ACTUALLY LOOKING AT THEM) over how well you control their cholesterol or even solve the problem they came in for. It’s not like we need to do this — we are being bullied into it by administrators and lawyers and bean counters so that they can save a few dollars and improve profits.

Every one of these stupid gimmicks that we allow to be forced upon us further erodes how much of a connection patients feel to us. And that connection is the only asset we have backing us up when we tell the bean counters to go to hell. It’s a vicious cycle… probably hopeless. Ah well, I went into a field where I can escape when it gets too bad.

A. N. Mous

Justify it to yourself however you need to to get through the day – but you’re not providing better care looking at a computer. And, my vet has pictures of my pets on their charts. No way in hell would I ever allow a photo of me to be part of my medical record. EVER! I am not a dog. I am a person. Saying this is a “safety protocol” is bv11$*+. I don’t believe you.

r watkins

I’m sorry, but this really sounds like guidelines on how to make the EMR the focal point of the visit, both for the doc and the patient. And don’t criticize the EMR because that might hurt its feelings.

http://www.mmfemr.com Leo

Very good points in this article. I think its important for Dr’s to practice common sense when dealing with EMR. Just make sure you aren’t typing away as if you were writing a book and keep in touch with your patient during the consult and you should receive minimum push-back.

Cypress

As a patient, I would rather see my doctor typing in an EMR than scribbling illegible notes on a piece of paper. The level of distraction is the same, whether the doc is typing or writing. I’ve never seen a doctor who can make eye contact with the patient while writing in a chart. What I often see is a doctor who enters the exam room with a clipboard in hand and eyes glued to the chart, reads my name off the chart, introduces himself to the chart while he scans my medical history, then sits down hunched over the chart, and starts writing.

If you can’t type and listen at the same time, then don’t. Most doctors can’t write and listen at the same time, but they try to do it anyway. I never understand why they keep asking questions when they haven’t finished writing yet. If my doctor asks me another question while writing down my answer to the first question, I sit and wait for him to finish writing before I speak. I don’t want my doc trying to multitask during my appointment.

Eye contact would be great, but patients don’t get any of that when their doctor is asking questions faster than he can take notes, scribbling furiously in a chart the whole time. And I’m usually horrified when I catch a glimpse of my doctor’s handwriting. It’s kind of important for the name and dose of my medication to be legible. Not to mention all that other important stuff that’s recorded in my chart.

And I know an electronic record won’t get lost. I’ve seen doctors open my file, only to discover that a page is missing. Manila envelopes aren’t the most secure storage system, you know. The first time I saw an EMR in my doctor’s office, I was impressed. I thought, “Finally, note-taking for the 21st century.” I understand that many older doctors might be put off by it, but for doctors of my generation, typing on a computer is as intuitive as writing with pen and paper. You don’t have to be a good typist. I was raised on computers, but I never learned to type properly. I have to look at the keyboard when I type, but I also have to look at the piece of paper when I write. It’s no different. At least with an EMR, you don’t have to worry if you have the penmanship of a dyslexic first-grader.

Here’s a tip, for those who need help: Do not talk and type at the same time. You should be typing while your patient is talking. If your patient has finished answering the question and you are still typing, then let there be silence. Your patient will wait for you, I promise. When you finish typing, THEN you can ask your next question.